Provider Demographics
NPI:1164940698
Name:MILLS, KYLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:MILLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 1ST AVE N STE 150
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-0002
Mailing Address - Country:US
Mailing Address - Phone:218-371-1690
Mailing Address - Fax:218-287-5928
Practice Address - Street 1:1104 W RIVER RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2723
Practice Address - Country:US
Practice Address - Phone:218-844-6853
Practice Address - Fax:866-226-6130
Is Sole Proprietor?:No
Enumeration Date:2017-09-05
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician